About ALPPS Procedure

For or a short introduction to the ALPPS Procedure, please click on the video from Dr Roberto Hernandez-Alejandros Group in London, Otario, Canada below:

"ALPPS"  stands for Associating Liver Partition and Portal vein Ligation for Staged hepatectomy. ALPPS is the most recent modification ot the techniques developed for Two-stage hepatectomies that allow resection of advances liver tumors in two steps by making use of the regenerative capacity of the human liver. ALPPS was first described in a publication in the Annals of Surgery by the liver surgery group led by Dr. Hans Schlitt in Regensburg, Germany (Schnitzbauer et. al, Ann Surg 2012.).

The first formal report of this novel approach was offered, as a series of 3 cases , on a poster presented by Dr. Hauke Lang, from Mainz, Germany , during the ninth E-AHPBA meeting in Cape Town, South Africa, April 2011 (Baumgart et al, HPB (Oxford) 2011; 13 (suppl 2): 1-145). Other cases and technical aspects  were also reported by the Liver Surgery group led by Dr. De Santibanes (De Santibanes et a. Wold J Surg. 2012; 36:125-128).

ALPPS allows to remove an extensive part of the liver in two steps. In the first step the liver parenchyma is transected along the intended line of resection and the future liver remant cleaned by partial resections from all tumor tissue in the case of bilobar tumors. To this a portal ligation of the larger liver lobe that will have to be removed is added. The patient is then allowed to recover. After a waiting period of 1-2 weeks the second step is performed in which the deportalized liver is removed to render the pateint completely tumor-free.

The new strategy offers two adavantages: First it elegantly addresses the most feared complication following major hepatectomies, i.e.  "postoperative liver failure". The dieseased right hemiliver, left in place, acts as an auxiliary livere to assist the future liver remnant for the first and critical week after resection. Second  this new operation induces an amount of hypertrophy that is unparalleled by other techniques. Schnitzbauer et al. report a 74% volume increase of the remnant liver in a mean of 9 days.

Considering the 5 stages of new surgical procedures "IDEAL" (Innovation, Development, Exploration;Assessment and Long term") as proposed by the Balliol group, the credit for the Innovation goes to the group led by Dr: Schlitt in Regensburg, Germany. Several groups worldwide have now used the new technique and were able to confirm the Regensburg results (Development) and share their experiences (Ann letters). For a more systematic Exploration two methodologies will become necessary: randomized controlled trials of multiple centers and registries of cases performed on the basis of the intent to heal individual pateints where standard approaches of two-stage liver resections might run a risk of not being able to resect their tumors completely.